#Poop and #belly #pain!

Too much stool? #orderwhat  @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Many radiologist would not specifically comment on stool burden.  I have made it part of my practice to include "Dense stool and air filled colon, correlate with signs and symptoms of constipation" when I see a radiograph like this.

If you get a normal report and you see the colon looking like this, consider constipation.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

Image credit:

http://pediatriceducation.files.wordpress.com/2009/01/122704constipationaxr.jpg?w=367&h=474

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Suspected Physical Abuse Child

2 years or younger? Over 2? Neurologic findings?  #NAT #orderwhat  @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

2 years old or younger, no focal neuro symptoms => Skeletal survey

2 or younger, head trauma with no focal neuro symptoms => Skeletal survey and non con head CT

2 or younger, WITH focal neuro symptoms => Skeletal survey and non con head CT, probably brain MRI

OVER 2, WITH focal neuro symptoms => Non con head CT, probably brain MRI

Any age with obvious chest, abdomen or pelvic trauma => Skeletal survey and indicated CT 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Vomiting infant - imaging needed? Bilious? X-ray or Ultrasound?

Vomiting In Infants Up To 3 Months Of Age?

Bilious vomiting in neonate up to 1 week old = abdomen radiograph and possibly upper GI or contrast enema

Bilious vomiting in infant 1 week to 3 months old = upper GI

Intermittent non-bilious vomiting since birth = possibly upper GI

New onset  projectile non-bilious vomiting = abdominal ultrasound 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Osteomyelitis in diabetic foot?

Imaging of suspected osteomyelitis in diabetic foot?

Summary

Soft tissue swelling with or without neuropathic arthropathy or with or without ulcer = foot X-ray AND MRI foot without and with contrast

If imaging is indeterminate, biopsy or aspiration is warranted

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

What is appropriate medical imaging?

Having been in radiology a number of years, I know it can be difficult to decide what is the best study, if any, for each patient. Radiation? Cost? Wait time? Contrast or not? MRI vs CT scan?

The American College of Radiology teamed up with many specialist to create the Appropriateness Criteria. It has the goal of helping providers better choose which study is best for their patients.

There is terrific information in this project, however it can be intimidating to navigate.

I will summarize a few per week, with links to the source documentation, as a primer for my friends who are not necessarily radiologists.

Fellow providers, please leave comments and I will address them to the best of my ability. Patients please see below.

This is the entire Appropriateness Criteria:

http://www.acr.org/Quality-Safety/Appropriateness-Criteria

This is also accessible from here:

http://www.guideline.gov/search/search.aspx?term=acr+appropriateness



Radiologists in training may benefit from these posts as well as the ABR Core Exam asks specific question from the ACR AC.

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Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Tweeting some more good info here! @helpfulrads

Acute pancreatitis? Ultrasound or CT? When?

#orderwhat #pancreatitis @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg #choosingwisely

Imaging for acute pancreatitis

First time presentation, abdominal pain, and increased amylase and lipase with high clinical certainty of diagnosis; LESS THAN 48–72 hours after onset of symptoms; clinical score irrelevant; 

unknown cause  => US abdomen to assess for gall stones

Everything else, probably => CT abdomen with contrast, see below.  

Critically ill, systemic inflammatory response syndrome (SIRS), severe clinical scores (eg, acute physiology and chronic health evaluation [APACHE], bedside index of severity in acute pancreatitis score (BISAPS), and/or Marshall); GREATER THAN 48–72 hours after onset of symptoms. => CT abdomen with contrast

Continued SIRS, severe clinical scores, leukocytosis, and fever; >7–21 days after onset of symptoms. => CT abdomen with contrast

Initial presentation with atypical signs and symptoms, including equivocal amylase and lipase values (possibly confounded by AKI or chronic kidney disease) and when diagnoses other than pancreatitis may be possible (bowel perforation, bowel ischemia, etc). => CT abdomen with contrast

Known necrotizing pancreatic and peripancreatic pancreatitis, significant deterioration in clinical status, including abrupt decrease in hemoglobin/hematocrit, hypotension, tachycardia, tachypnea, abrupt change in fever curve, or increase in white blood cells; time
after symptom onset irrelevant. => CT abdomen with contrast

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Foot trauma? Foreign body? X-ray needed?

Acute foot trauma? - #orderwhat #footpain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Meet Ottawa Rules or not neurologically intact  => Xray

Concern for Lisfranc injury => Weight bearing Xray, if able or MRI foot

Does not meet Ottawa Rules => No study indicated

X-rays negative and concern for tendon injury or dislocation => MRI foot

Penetrating trauma and concern for foreign body => X-ray, then US if needed 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Knee Trauma

Acute knee trauma? - #orderwhat #kneepain @AFPjournal @PCareProgress @AANP_NEWS @AAPAorg

Acute knee trauma, fall or twisting injury with:

No focal tenderness or effusion and able to walk => no study indicated

Focal tenderness, effusion or unable to walk => X-ray then MRI if needed.

Suspect tibial plateau fracture on xray => CT knee

Suspect posterior dislocation => X-ray and MRI and possibly angiography. 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Ankle Trauma?

Suspect Ankle Fracture

Summary:

Ankle radiograph if patient meets Ottawa Rules: 

Can’t bear weight immediately after injury 

OR 

Point tenderness over medial malleolus, posteroinferior lateral malleolus, talus or calcaneus 

OR 

Cannot walk 4 steps in emergency department



If one of these describes the patient, an ankle radiograph is appropriate.

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Dyspnea, suspected cardiac origin?

Dyspnea of suspected cardiac origin

Summary:

Chest xray and transthoracic echocardiography (possibly followed by a stress: echo, SPECT or PET or Cardiac MRI) 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon

Knee pain without trauma. Is there an effusion? Degenerative changes?

Imaging for knee pain without trauma. Is there an effusion? Degenerative changes?

Summary

Child, adolescent or adult knee pain without trauma = knee X-ray  

Child, adolescent or adult knee pain without trauma and knee X-ray is negative or shows effusion or secondary signs of trauma = MRI knee without contrast

Adult knee pain without trauma and knee X-ray shows avascular necrosis = possibly MRI without contrast if it directs therapy

Adult knee pain without trauma and knee X-ray shows degenerative changes, crystalline arthropathy or chondrocalcinosis = Probably NOTHING 

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Acute hip pain, suspect fracture?

Imaging of acute hip pain, suspect fracture?

Summary:

First study middle aged or elderly = Xray hip, AP and cross table lateral and Xray pelvis, AP view BOTH

Negative or indeterminate radiograph, then = MRI hip/pelvis or CT hips

(Note if fracture and minimal trauma, eval bone density with DEXA scan)

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Imaging of solitary pulmonary nodule?

Imaging of solitary pulmonary nodule?

Summary:

Nodule discovered on chest radiograph, **greater** than 1 cm and low, moderate or high clinical suspicion for cancer = CT chest without contrast,  if CT indeterminate then PET CT whole body and biopsy if PET avid or enhances.

Nodule discovered on chest radiograph, less than 1 cm and low clinical suspicion for cancer = watchful waiting with CT follow up or CT chest without contrast (Note: Fleischner Criteria not addressed in this publication)

Nodule discovered on chest radiograph, less than 1 cm and moderate to hight clinical suspicion for cancer = CT Chest and possible biopsy or follow up CT chest.

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Rib trauma

Suspected rib fracture?

Summary:  Less than or 65 years old = Chest radiograph, PA view only.

                   66 years old or older = Chest radiograph, PA view (with possibly rib series, if that will direct care, tertiary or ICU)

                   

93% of patients with either clinical or radiograph diagnosed rib fractures went back to normal daily activities and did not need a follow up X-ray.  

Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources? Am Surg. 2002;68(5):449-453.

As always, please refer to the source Appropriateness Criteria created by the American College of Radiology, here.

Educational purposes for licensed providers.

Note to Patients:

Radiology is a very large and ever changing field and this post is to help your provider.  When combined with a thorough history and physical exam, this information can be very useful.  Your provider is best suited to answer specific questions regarding this post.

A provider is usually a Nurse Practitioner, Physician Assistant or Medical Doctor.

Of course, this is not a substitute for medical care.

More about Dr. Vachon - ORAinformatics.com

Please Link In! www.linkedin.com/in/tyvachon